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Introduction • A rise in global opioid consumption has led to an increase in negative consequences associated with prescription opioids • Opioid analgesic dependence (OAD) has become a global concern but is poorly documented in Europe • Populations who misuse over-the-counter (OTC) or prescription only (POM) opioid analgesics are at risk of developing OAD • More guidance is required to aid healthcare professionals in the clinical management of OAD 1 Opioid analgesic consumption is increasing on a global Canadians are the second largest per capita consumers of narcotics and prescription opioids scale outside of Europe Opioids were involved in 43% of all drug overdose deaths in the US in 2010. They were responsible for more than twice the number of deaths from heroin and cocaine combined Prescription opioids are the most abused opioids in Brazil Non-medical use of pharmaceutical opioids doubled between 2007 and 2010 in Australia Source: INCB report 2012; INCB statistics for 2011, 2012; CM Jones et al. 2013; I Giraudon et 2 al. 2013; A Roxburgh et al. 2013. Canadian Centre on Substance Abuse, Prescription Drugs http://www.ccsa.ca/Eng/topics/Prescription-Drugs/Pages/default.aspx The size of the OAD problem in Europe is poorly defined An estimated 455,000 people dependent on prescription opioids in 2013 The true extent of non-medical uses of OTC and POM medications is unknown: treatment seekers often cite OTC/ POM meds as their drug of choice 17 European countries reported 10% or more of first-time opioid patients entering specialised treatment were using opioid medications other than heroin Source: H Alho ISAM 2013; European Monitoring Centre for Drugs and Drug Addic6on. 3 developments. 2014. L Weich et al. 2015 European Drug Report: Trends and People dependent on opioid analgesics are different from those dependent on heroin Illicit heroin dependence OAD OAD populations may result from: 1. Iatrogenic dependence on prescription only (POM) or over the counter (OTC) opioid analgesic preparations following treatment for pain 2. Dependence on illegally acquired/ diverted POM and OTC analgesic preparations Source: RGCP 2013 Addiction to medicines Factsheet 4 4 6 factors highlight individual OAD risk; personal family history of dependence is strongest predictor Personal/ family history of dependence Genetic predisposition Drug exposure Risk factors Brain reward mechanism alteration Frequent prescription analgesic use, low pain threshold Psychological profile Source: J Højsted et al. 2007; TJ Ives et al. 2006; MJ Edlund et al. 2007; J Elander et al. 2014; 5 Physical, psychological and social consequences highlight the importance of treating OAD Physical Psychological Social • Vary with opioid intoxication, overdose or withdrawal • Mood instability • Loss of employment • Agitation • Marital & family breakdown • Long term effects:1 • Depression • Anxiety • Endocrine changes • Hyperalgesia • Immunological effects • Sleep disorders • Loss of friendships • Loss of interest in regular activities • Financial problems Source: British Pain Society. Opioids for persistent pain: Good practice. 2010 6 Challenges for addiction specialists in OAD management • How to help a patient address their opioid misuse without diminishing their pain control • How to accommodate and treat patients that do not fit the traditional model of treating street drug users Challenges • Understanding how these new patients’ needs relate to the needs of existing patients • How to develop effective and collaborative joint working methodologies with local pain services 7 An integrated treatment plan, multidisciplinary team with adjunctive therapy is recommended Team Planning Adjunctive & psychosocial therapies Primary care physicians Pain Integrated specialists treatment Mental health specialists • Plan psychological and social support depending on need Addiction specialists • Consider social problems: unstable housing, lack of employment • Mutual aid services and support groups might be useful 8 Specific Management Tool OAD Treatment Algorithm Treatment assessment Treatment selection Treatment monitoring Recovery from dependence • Dependence on opioid analgesics requires specific management which is supported by international guidelines and a body of evidence • A decision-tool may be useful in OAD management • There is an opportunity to improve outcomes in OAD by making clear choices in management • Future work should define better outcomes in OAD with different interventions 9